The Courage of the Harm Reduction Therapist

A master therapist discusses the things that can keep him up at night in his work with clients who are still using substances.

This week Professional Voices features an interview with Dr. Tom Horvath, a leader in the progressive treatment of addictive disorders and a contributor to The Fix. Horvath is the president ofPractical Recovery,and the volunteer president ofSMART Recovery. The interview highlights some of the challenges faced by clinicians who don’t demand abstinence as a prerequisite, or even a goal, of treatment.

I think that nearly everyone in the addiction treatment field practices harm reduction, but they may not describe what they do that way.

Richard Juman: In thinking about taking a harm reduction approach in working with people with alcohol and substance use disorders, one of the aspects to consider is that it really takes some courage to work in this way. On an important level, it seems that an abstinence model is much easier on the clinician. For example, if a patient overdoses or gets into a car accident after drinking, the abstinence-based therapist is “off the hook” because his position was that the client should not have been using at all. On the other hand, if as a therapist you are accepting of ongoing drinking or substance use, then you are putting yourself at risk, perhaps not legally, but as a clinician and a human being, if there is a negative outcome. Do you agree?

Tom Horvath: For a professional coming from a traditional (12-step, disease model) perspective, the shift to harm reduction does require courage! Regardless of treatment perspective, all professionals want good outcomes for their clients, and professionals want to do what they can to be helpful. In the traditional perspective, giving the advice to abstain (“because you are an addict/alcoholic and have to abstain”) is seen as essential. The advice follows from the diagnosis. If the professional is used to operating that way, not doing so is scary.

From the harm reduction perspective, at least as I understand it, the diagnosis is largely irrelevant (at least from the perspective of how much of any substance the client is going to use) because the primary issue is what the client is motivated to do. How can I help this client accomplish her goals in life and reduce any dangers arising from substance use?

By analogy, if this person is going to rock climb, can I suggest ropes, harnesses, and other equipment so that the dangers of falling are reduced? I will likely discuss the risks of rock climbing, to confirm the person is adequately informed (“you know you can die or be seriously injured?”). But I will recognize that this person has decided to climb, and I’m not responsible for the outcome. If I insist “you should not climb” I think there is the significant risk the person, in reaction , will climb and pay little or no attention to safety. My hope is that by not “forbidding” climbing, but by instead focusing on safety, I can, over time, build up a greater safety awareness, ultimately leading to no climbing or much safer climbing.

If a client is already motivated to abstain, my advice is not needed. If she isn’t motivated to abstain, I usually frame my comments in a “double-sided” way (a term used in motivational interviewing). I might say:

“To summarize our discussion thus far, you are aware that if you drink even one drink at this event, there is a higher risk that you will have a binge later that night, and that outcome is quite unappealing to you. You are also aware that if you don’t drink, you may be thought badly of by some of the people there, and that outcome is also quite unappealing to you. What would be best is drinking moderately without troubles, or abstaining and having no one think anything bad about your behavior. These are the two options you are considering. At the moment you are strongly leaning toward moderating. If so, how about if we talk about how to increase your chances of being successful?”

If the client aims to moderate but binges instead, our next session will focus on what went wrong. Also, and this is critical, there is a very good chance that she will show up for that next session, because the client will not expect to be shamed. Working in this way, there is less of a chance that the therapeutic alliance will be damaged by any of her behaviors, because we have already had an open dialog about those situations.

Sometimes a client’s situation is so difficult that I may ask: “Can you afford to have even one more problem? Isn’t your wife about to divorce you? Do you really want to take that kind of risk?” I may also another give another “margin for error” analogy that involves falling from great heights: “When you visit the Grand Canyon, there are places you can stand where, if you fall over, you are going to fall to your death. When I’m there, I stand a body length away from the edge. I don’t expect to fall down out of the blue, but I like to have that much margin for error, because in that situation I have so much to lose! Is it exciting to you to play it so close? What stops you from having a greater margin for safety?”

In any event, the client’s choices are the client’s choices. I am not responsible for them. Interestingly, in nearly 3 decades of doing addiction treatment, I may have been asked once “Do you think I should abstain?” I think clients want our consultation, but not our advice.

RJ: I would imagine that people are referred to you, or seek you out, because it is known that you practice in this way- that you don’t demand abstinence instantly, or maybe ever. Are new clients ever surprised, or taken aback, by how willing you are to work with them while they’re still using?

TH: Most people (90%) come to my treatment system, Practical Recovery, knowing that they want either outpatient or residential treatment (or rehab). The rehab clients know they are expected to abstain while in the facility, and most expect to abstain afterward. By the time you are ready to enter rehab, typically for weeks to months, your addiction problems are likely very substantial. You have tried moderation and not succeeded, probably several times. However, some of these clients hope to moderate later. We tell them we’ll focus on abstinence for now, and they can consider moderation later.

Outpatient clients are generally more undecided, but a substantial percentage (I estimate 50%) still want abstinence. Some clients are surprised by our willingness not to require abstinence, but they quickly realize that we want them to make choices about all aspects of their recovery. For instance, we help them figure out if they should socialize with their current friends or make new ones? Whether they should attend groups or just individual therapy? If they should also attend mutual help groups (such as SMART Recovery or 12-step programs)? For each question, we attempt to help them make an informed and sensible decision, consistent with their goals, values and situation.

RJ: Are there times when you are really nervous or lose sleep because a patient is “out there,” playing a little too close to the edge?

TH: Yes, sometimes. Some people are slow learners about recovery, regardless of the recovery approach. This is a risky “game.” Of the approximately 70 residents we admitted in the first year to our co-ed rehab, two are dead. I don’t know how many treatment centers would talk about this kind of fact. I don’t think our numbers in this regard are outside the norm. Substance use kills people, but part of the addictive experience can be the idea that “it won’t happen to me.” In most cases it doesn’t, but sometimes it does. Many of us could go our whole lives not wearing seat belts, and have no problems. But if everyone stopped wearing belts we’d have a lot more deaths. When you have significant addiction problems it is like not wearing your seat belt. You have a much higher risk of major problems, including death.

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RJ: What do you when you are convinced that a client is at too much risk and really needs to go inpatient but they refuse? Are there people that you’ve discontinued treatment with because you feel they are ignoring their own safety and you don’t want to participate?

TH: I propose lots of ideas for clients to consider. If outpatient doesn’t seem to be working, yes, I would propose rehab. However, I can’t force people into rehab, and if it gets to that point all I could do would be to refuse to see someone, which is a rare occurrence in our practice. Over my entire career I have probably told just a few clients that I did not see the value in continuing our sessions. If the sessions are not meaningful, if the addiction is no better, and if someone else is paying, then I have stopped seeing someone. I do not want to give the impression that “we’re working on it” when we are not. Some people enter treatment (for all kinds of problems) with no serious intention of change, but want to be able to say “I’m working on it.” However, if the individual really is “working on it,” then I’m very patient, because there might be a lot to work on.

RJ: Do you have any final thoughts about the courage required to work in harm reduction from the standpoint of the therapist’s own comfort level with risk?

TH: At one time I was taught that the therapist should state his expectations of the client, and if the client didn’t meet them, it wasn’t the therapist’s problem. What happens when you take this approach is that, even though you may not feel responsible, you can see that some expectations are unrealistic. I named my treatment system Practical Recovery because we genuinely attempt to create recovery plans that are realistic. A plan is not realistic if someone is less than fully interested in following it. For many clients, recovery progresses by degrees, small steps at first, larger ones later. Many kinds of learning happen in this incremental way, but the big difference is that unlike, for instance, learning to play the piano, if you play your scale incorrectly it won’t kill you. Nevertheless, I think we would help more people by moving in small steps, rather than asking for big steps that many or even most people won’t make. So for me, ultimately, harm reduction does not require more courage than abstinence-based work because I believe it is the more sensible approach and the one more likely to produce good outcomes.

I think that nearly everyone in the addiction treatment field practices harm reduction, but they may not describe what they do that way. For example, when clients in abstinence-focused outpatient programs relapse, they’re usually not terminated from treatment. Instead, they may be offered a relapse prevention group or more intensive individual psychotherapy. But a larger issue about harm reduction, for me, is how you measure success for each client. Consider the concept of “chemical dependency.” You might have a client who is abstinent from intoxicating substances (chemical dependencies) but continuing to harm himself with food, cigarettes, caffeine, promiscuous sex, problem gambling, electronics or other high-risk behaviors. Technically you’d have an abstinent, “successful” case, but really you would would want to continue treatment, continue the harm reduction work, because more improvement is possible in these other areas. Chemical dependency is a harm reduction term, but it’s not usually recognized as such. Accepting some progress in the service of a person’s individual recovery journey, without demanding “complete” progress, is one aspect of harm reduction. I hope that accepting that progress can be gradual, embracing positive changes incrementally as opposed to demanding more progress at a pace that suits the therapist, as opposed to the client, will eventually be embraced by the entire treatment community.

Richard Juman, a licensed clinical psychologist who has worked in the integrated health care arena for over 25 years, providing direct clinical care, supervision, program development and administration across multiple settings, is also former President of the New York State Psychological Association.